Step by step
Abdominal cavity approach
Perform a mini transverse incision, transverse right incision, or the upper midline incision; see specific course ‘Abdominal Wall Incision’.
Inspect the abdominal cavity paying special attention to the condition of the gallbladder (adhesions, inflammation) and liver (cirrhosis).
Preserve the abdominal organs using large gauze.
Retract the liver cranially by placing a blunt retractor at the left side of the gallbladder.
Retract the fundus of the gallbladder cranially by placing an atraumatic ovum forceps at the fundus.
If the gallbladder is expanded due to the presence of gall, the forceps cannot be placed. The manner to decompress the gallbladder is to puncture it and to drain the bile.
If present, dissect any adhesions off the gallbladder.
Dissection plane exposure
Keep the gallbladder under tension and put traction on the adhesions to identify the dissection plane, staying close to the gallbladder.
Incise the peritoneum at the fundus of the gallbladder.
Dissect the gallbladder towards the infundibulum from the liver bed, until it is only attached at the infundibulum.
Bile ducts and vessels injury
When dissecting with electrocautery, care has to be taken to avoid thermal injury to billiary ducts and vessels.
Dissection plane exposure
Keep tension in opposite directions to expose the plane of dissection between liver and gallbladder.
Transect the lateral peritoneum so the the lower edge of the gallbladder becomes visible.
Be careful not to injure any tubular structures.
Identify the cystohepatic triangle, bound by the common hepatic duct medially, the cystic duct laterally and the liver margin superiorly.
Cystohepatic triangle identification
All constituents of the cystohepatic triangle must be identified to avoid cutting or clipping the wrong structures.
Critical view of safety
Dissect the cystohepatic triangle to obtain the critical view of safety: the isolated cystic artery and cystic duct entering the gallbladder, with liver tissue in the background and a cleared cystohepatic triangle.
Critical view of safety
When it is possible to obtain a clear critical view of safety, the transection of the cystic duct and the cystic artery are shown in the film ‘open antegrade cholecystectomy’.
When it is impossible to obtain a good critical view of safety as a result of infiltration of the infundibulum and neck; the gallbladder should be opened, as shown in the film. Enter the opened gallbladder with an index finger and palpate the neck of the gallbladder. Try to identify the cystic duct opening.
Cystic artery and duct
When the cystic artery and duct cannot be identified, use the entered index finger to identify the lower border and the neck of the gallbladder. The neck of the gallbladder can be clamped with a blunt dissection forceps and transected, leaving a small rim of gallbladder in situ.
Remove the gallbladder.
Abdominal wall closure
Irrigate the abdominal cavity.
The closure of abdominal wall incisions are described in detail in that specific course.
- Hepatoduodenal ligament
- Cystohepatic triangle
- Abdominal cavity
- Fundus of gallbladder
- Infundibulum of gallbladder
- Neck of gallbladder
The main surgical objective of the cholecystectomy is to prevent future symptoms and complications of gallstones or acalculous cholecystitis, by surgically removing the gallbladder. In order to reach this objective, it is essential that a clear anatomical overview is achieved intraoperatively to avoid damage to the bile duct and other surrounding structures.
Besides the cholecystectomy, the following (surgical) alternatives may be applied for the same indications:
- Medical dissolution therapy for symptomatic gallstones
- Expectant management for asymptomatic gallstones
- Cholecystostomy for acute cholecystitis
A cholecystectomy can either be performed using a laparoscopic or open approach using the antegrade or retrograde technique.
Open versus laparoscopic
The preferred approach to performing a cholecystectomy has shifted from an open to a laparoscopic mode. However, some situations still may require a traditional open cholecystectomy:
- Suspected or confirmed gallbladder cancer confined to the mucosa or muscle layer (stage T1). When confirmed during a laparoscopic removal, the trocar portal sites must be excised completely.
- Type II Mirizzi syndrome
- Gallstone ileus
- Advanced cirrhosis, portal hypertension or bleeding disorders.
Single Incision Laparoscopic Surgery (SILS) and transvaginal Natural Orifice Transluminal Endoscopic Surgery (NOTES) are laparoscopic techniques to further minimize the invasiveness of the procedure. Their efficacy, complication rates and aesthetic outcomes are still under investigation.
Antegrade versus retrograde
In the retrograde technique (fundus first) dissection starts at the fundus of the gallbladder and continues to the triangle of Calot and the portal triad. With this technique the remaining two attachments to the gallbladder are the cystic duct and cystic artery.
In current laparoscopic surgical era to which we belong, the antegrade technique (fundus last) is the most common technique used. The dissection starts at the triangle of Calot, with ligation of the cystic duct and artery and continues upward, dissecting the gallbladder off the liver bed.
INSTRUMENTS AND MATERIALS
For the open cholecystectomy a basic laparotomy instrument tray is used.
The patient is placed in the supine position, with both arms extended. Inverting the table to the left during the procedure increases the exposure of the gallbladder.
Besides general postoperative complications, specific biliary complications can occur after a cholecystectomy such as bile leakage.
Bile leakage after cholecystectomy causes persistent abdominal pain secondary to chemical peritonitis. In severe cases, an ileus, fever and hyperbilirubinemia can occur.
These complications may be the result of leakage of bile from the liver bed, an accidental transected aberrant bile duct, an insufficient cystic duct stump ligature, or bile duct injury.
Once diagnosed, an endoscopic retrograde cholangiopancreatography (ERCP) can further assist in recognizing the leak as well as conduct therapeutic options.
Attempts of repair of the leaks by inexperienced surgeons usually cause more damage to the structures postoperatively. In case an experienced surgeon is not immediately available for referral it is best to only introduce a drain in the abdomen and refer the patient to a specialist center for adequate repair.